K.M. Venkat Narayan: Chronic Diseases – a Major Global Challenge that Threatens Health and Economies AlikeSeptember 20, 2010
The impact of chronic diseases to the health and well-being of the world is a growing threat – not only to the health and well-being of people from all countries but to all economies – rich and poor — as well.
Already, Mexico is overtaking the United States in the proportion of people obese and overweight. And in India and China, the prevalence of diabetes is much higher than the United States. In urban India the prevalence rate of diabetes is about 16-18% and in the United States it’s about 9%.
In fact, six of the top 10 risk factors for mortality worldwide are chronic disease not infectious diseases, according to a recent report from the World Health Organization. They include high blood pressure, tobacco use, high blood glucose levels, physical inactivity, overweight or obesity and high cholesterol levels.
These risk factors pervade countries of all income levels, even in low-income countries.
A lot of the solutions are going to require active global cooperation, such as what’s being done in climate change. But the awareness is not there yet. Most governments and funders believe that in developing countries the most pressing issues are only with infectious diseases, undernutrition and maternal mortality. People with chronic diseases are most vulnerable to infectious diseases. People with undernutrition are vulnerable to chronic diseases. So, these are all inter-connected problems. The biggest impact on Millennium Development Goals (MDGs) for HIV and tuberculosis reduction and infant andchild mortality could be to invest in chronic diseases – may sound counter-intuitive and paradoxical, but data support these assertions. Although chronic diseases are not part of the MDGs, we cannot meet the MDGs unless we invest in chronic disease prevention and reduce their impact on mortality. Without a huge investment in chronic disease prevention, economic activity will greatly decline because of the loss to workforce and health care costs. This will affect high-, middle-, and low-income countries all alike.
Solutions need to come in three main forms: 1) At the policy level, major economic lenders like the International Monetary Fund, World Trade Organization and national governments need to address chronic diseases with a sense of urgency. 2) At a consumer level, transfats should be banned like cigarettes; salt in processed foods should be reduced; there needs to be stringent regulations on food labeling; strategies need to focus on reducing intake of refined carbohydrates, and there needs to be promotion of healthy fruit and vegetables. 3) At the health-system level, more attention needs to be given to chronic diseases. This means health systems need to be strengthened and reoriented toward prevention and management of chronic diseases. Trials have shown that 50-60-% of diabetes could be prevented if there were prevention-oriented clinical systems focused to chronic diseases rather than an acute medicine model of care.
For more on this topic, see the perspectives article “Global Noncommunicable Diseases — Where Worlds Meet” published in the New England Journal of Medicine Sept. 15 by Emory researchers, including myself, Mohammed K. Ali and Dr. Jeffrey P. Koplan.
As budget constraints tighten and we think about how to invest our education dollars at universities, tax payers have a right to expect a return on that investment. When it comes to global health studies at universities, that return is not always obvious. As I talk to people across King County and the country, I find that they tend to think of “global health” as something that benefits people overseas. Yet, we increasingly find that global health is a two-way street. What we learn and the strategies we use in global health can also greatly improve health in our own country.
Reality check: Although the United States has the world’s best medical system, we do not live as long or as well as Bosnians or Jordanians. The U.S. is not even one of the top 25 countries with respect to indicators of health. Why? Because although we have poured money into our clinical health care system, we have neglected community health. As a consequence, communities across America have health indicators on a par with those in developing countries.
What global health strategies might also work at home to improve health? One example is community health workers–people from the community who are trained to deliver frontline health information to their neighbors. It’s low cost and highly effective, particularly for reaching communities that have been marginalized on the basis of culture or language, and whose members may have difficulty understanding or accessing health care professionals.
Global health also teaches us that technology can leapfrog over barriers in delivery. For example, across much of the developing world, cell phone technology is filling in for a lack of physical infrastructure—like roads and health clinics. We could make some of the same leaps: video phones can be used to watch people take their tuberculosis medicine rather than having to send an expensive healthcare worker to the patient’s house. Or we can use cell phones to deliver messages in an emergency in languages that are understandable to non-English speakers.
Additionally, we should borrow a page from global health in our approach to linking health and economic development. We know that poor health is strongly linked to poverty. Globally, micro-credit loans are being used to improve family income and health. Why not do the same here? For example, microloans could even pay for citizenship applications—which cost $700. The benefit: citizenship is linked to higher incomes and higher incomes are linked to better health. But many who are qualified and would like to become U.S. citizens cannot afford the application fee. And all loans need not be “micro”. Larger low interest loans could enable corner groceries in poor neighborhoods to invest in the equipment for stocking healthy, nutritious fresh fruits and vegetables.
Let’s use the conference of the Consortium of Universities for Global Health to build out such ideas and to establish the collaborations that can make them happen. Global health and local health is a two-way street. The job in front of us is to make it well traveled in both directions.
David Fleming, M.D.
Director and Health Officer for Seattle and King County Public Health
A lack of capacity is one of the major restrictions to development and human security in low income countries (LICs). Only 10% of the world’s research is done on the disease burden shouldered by the worlds poorest. Building and retaining the human skill sets needed by LICs is one of the great challenges of our time.
There is a way to tackle this problem by utilizing the highly skilled individuals in universities in the West to train people in LICs. I have a proposal for universities in the West to develop Centers for International Health and Development (CIHD) in their institutions. These centers will act as a conduit to link their universities with institutions in the south and facilitate North/South and South/South partnerships. By using a multidisciplinary approach, doctors, nurses, engineers, public management specialists, social scientists, and others, our universities can be used to develop these skill sets in LICs. The private sector, NGOs and government institutions can also be brought together to fund and implement these activities.
Building and retaining the skill sets needed for a competent and incorrupt public service, judiciary, and private sector is essential for any country to develop. Guided by the recipient nation our universities can play a crucial role to make this happen and in so doing will help developing nations break the shackles of poverty.
Hon. Keith Martin, M.D., M.P.
Parliament of Canada